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1. Executive Summary
Tissue ulcers are an important cause of morbidity and mortality amongst our frail elderly patients, both within hospital and in an out-patient setting.
Peripheral ulcers represent a great burden both to the patient and to the Health Service. Broadly there are four types of ulcer:
- Arterial ulcers – which are life and limb threatening
- Venous ulcers – which have a high social impact, are difficult, time consuming and expensive to manage and recur
- Diabetic foot ulcers – which are limb threatening and recur
- ‘Other’ – including vasculitis ulcers and malignancies – are difficult to diagnose and challenging to treat.
Accurate diagnosis, correct treatment and appropriate specialist referral is essential in their effective management. Pressure ulcers and peripheral ulcers are multidisciplinary challenges involving teams from several areas, including but not exclusive to:
- Tissue Viability
- Vascular Surgery
A thorough and holistic understanding of these complex clinical scenarios will benefit from engagement with the above teams.
Pressure ulcers are an unwanted complication of illness, severe physical disability or increasing frailty. Pressure ulcers cause immense suffering and considerable increases in length of stay. An understanding of the causes of pressure ulceration is fundamental to prevention of occurrence. Risk factors can be reduced, early change detected and appropriate management instituted. Engagement with the tissue viability team and understanding of available interventions is essential. Knowledge of age related skin changes and conditions/risks are required for effective clinical intervention and prevention of pressure ulcers.
Pressure ulcers are caused by pressure and/or shear forces over a bony prominence in the presence of a number of risk factors, the most important of which is immobility. A number of medical conditions such as chronic obstructive pulmonary disease; cerebro-vascular accident; diabetes mellitus; hip fracture and hip surgery have been significantly associated with pressure ulcers. Geriatricians, nurses and AHP’s thus have an important role to play in the prevention and management of pressure ulcers through and awareness and understanding of current best practice. All grade 3.4 pressure ulcers are now reported as a Serious Incident, and may be further investigated under Safeguarding protocols.
It must be accepted that it is not possible to prevent all pressure ulcers, but with appropriate care, the majority can be prevented. Prevention strategies need to address the specific risk factors identified in the initial assessment. The commonest strategies are:
- Pressure relief by means of repositioning and/or the use of pressure redistributing equipment
- Consideration of the needs of patient when seated in relation to pressure relief
- Improvement of nutritional status
- Skin care including on-going monitoring of skin status and any indications of pressure damage.
Many of the strategies used for pressure ulcer treatment are the same as those employed for pressure ulcer prevention, although they may be more intensive than those used in prevention. Assessment of the pressure ulcer should include:
- Category – shows severity
- Position on the body – may affect dressing selection
- Level of exudate – will affect dressing selection and frequency of dressing change
- Pain assessment – many ulcers are painful for the patient
Healing may not be a fast process, but generally if the patient has adequate pressure redistribution, good nutrition and appropriate wound management, the ulcer will heal in most instances.
Health professionals working in the specialty will encounter individuals at risk of pressure ulceration as well as those with established pressure ulceration on a regular basis. As part of Comprehensive Geriatric Assessment and MDT working they are best placed to manage such individuals appropriately. Additionally, familiarity with risk stratification scales and relevant, often local, guidelines and policies will prove invaluable adjuncts to optimal management.
Pressure ulcers are an unwanted complication of illness, severe physical disability or increasing frailty, and if left untreated can lead to serious harm and death (National Patient Safety Agency, 2010). They are caused by pressure and/or shear forces over a bony prominence. There are a number of risk factors associated with pressure ulceration, the most important of which is immobility. Additional risk factors include poor nutritional status, loss of sensation, poor perfusion and alterations to intact skin, possibly due to a previous history of pressure ulcers. Furthermore, a number of medical conditions were found to be significantly associated with pressure ulcer development including: Alzheimer’s disease; congestive heart failure; chronic obstructive pulmonary disease; stroke; diabetes mellitus; deep venous thrombosis; hip fracture; hip surgery; limb paralysis; lower limb oedema; malignancy; Parkinson’s disease; rheumatoid arthritis; and urinary tract infections. Pressure ulcers have their highest prevalence amongst older people with frailty, and Geriatricians, nurses and AHP’s thus have an important role to play in the prevention and management of pressure ulcers through and awareness and understanding of current best practice.
A review of death and severe harm incidents reported to the National Reporting and Learning System (NRLS) found that pressure ulcers were the largest proportion of patient safety incidents in 2011/2012. (National Patient Safety Agency).
There are no published national audits of the prevalence of pressure ulcers in the UK. Studies undertaken in a variety of different UK health care settings have reported a prevalence of between 7%-33%. In the last decade, surveys in other countries found a prevalence in the range of 10-22% of in-patients. The European Pressure Ulcer Advisory Panel published a pilot survey in 5 European Epidemiological studies in 2005, including over 2500 patients from 15 hospitals in the UK, and found a UK prevalence of 23%, or 13.9% if only including Category 2 or above ulcers (Vanderwee). The prevalence of pressure ulcers is now 1 of the 4 common harms recorded in the NHS Safety Thermometer, which measure, monitor and analyse patient harms across a range of settings on a monthly basis.
3. Definitions / Terminology
The following definition is the most recent and developed for international guidelines by the National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel (NPUAP/EPUAP, 2009) in a joint collaboration.
A pressure ulcer is localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.
This pressure ulcer classification is used widely across the UK. The term category, rather than grade or stage, is now preferred. However, both terms are equally widely used.
Category 1: Non-blanchable erythema
Intact skin with non-blanchable redness of a localized area usually over a bony prominence.
Category 2: Partial thickness skin loss
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister.
Category 3: Full thickness skin loss
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.
Category 4: Full thickness tissue loss
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present.
The additional category of unstageable is also recommended by the Tissue Viability Society for reporting systems within England (TVS, 2012).
Unstageable/ Unclassified: Full thickness skin or tissue loss – depth unknown
Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, grey, green or brown) and/or eschar (tan, brown or black) in the wound bed.
Moisture lesion: not a pressure ulcer
Redness or partial thickness skin loss involving the epidermis, upper dermis or both. Caused by excessive noisture to the skin from urine, faeces or sweat. This is not a pressure ulcer and must not be confused with a Grade 2 pressure ulcer which is caused by pressure.
4. Health Policy and Guidance
There are numerous policy documents and guidelines in relation to pressure ulcers (all accessed 14 July 2017).
The Care Act (2014) www.legislation.gov.uk
Health Improvement Scotland Best Practice Statement: http://www.healthcareimprovementscotland.org/previous_resources/best_practice_statement/prevention_and_management_of_p.aspx
Skin Bundle in Wales: http://www.1000livesplus.wales.nhs.uk/opendoc/179648
NICE Pressure Ulcer Quality Standard 2015: http://www.nice.org.uk/guidance/qs89
NICE Nutrition support in adults Quality Standard 24 (2012) http://nice.org.uk/guidance/qs24
Stop the Pressure http://nhs.stopthepressure.co.uk
Clinical Practice Guidelines for the Prevention and Treatment of Pressure Ulcers: http://www.epuap.org/guidelines/
National Patient Safety Agency NHS to adopt zero tolerance approach to pressure ulcers: http://www.npsa.nhs.uk
NHS Safety Thermometer www.safetythermometer.nhs.uk
5. Pressure Ulcer Prevention
It should be accepted that it is not possible to prevent all pressure ulcers, but with appropriate care, the majority can be prevented. At a very simple level, prevention means identifying those at risk and instigating appropriate prevention strategies according to individual need. However, it is not always straightforward to recognise those at risk. A number of risk calculators are available for use, but they all have limitations and so produce false positives (those deemed to be at risk who do not get a pressure ulcer) or false negatives (those whose score says they are not at risk but who develop pressure damage). NPUAP/EPUAP (2009) recommend that risk assessment should include a comprehensive skin assessment and clinical judgement as well as using a risk calculator. Risk assessment and screening of individuals admitted to any care setting should take place within 6 hours of admission.
Skin assessment should initially be undertaken by a registered nurse, to identify potential areas of vulnerability. Using a validated tool, such as the Waterlow ensures consistency in assessment. Many care settings have now adopted the SSKIN care bundle A care bundle is a collection of interventions (usually no more than 5that may be applied to the management of a condition. This prevention bundle is to be used has been identified as being at risk. The components of the SSKIN bundle are:
Surface, Skin inspection, Keep moving (repositioning), Incontinence and moisture, Nutrition and hydration
Pressure relief is the most important prevention strategy and traditionally was achieved by the use of ‘2 hourly turning’. These days a wide range of pressure redistributing equipment is available.
For lower risk patients, pressure relieving equipment is designed to distribute the body weight over as large as possible skin surface area- e.g. specialist and memory foams or static air mattresses. Pressure relieving equipment is designed to redistribute body weight periodically over different areas of skin e.g. dynamic mattresses and cushions. It is important that whenever possible patients should be seated in a position that allows them to maintain function as well as reducing pressure and shear. This may require the use of a footstool or foot rest to ensure that feet are not left dangling if they do not reach the floor. Patients should not be left sitting in a chair for long periods of time without pressure relief.
Skin assessment is the only way of identifying signs of tissue damage, and is often overlooked in a medical assessment. It should be an ongoing process as it is the most effective way of determining the effectiveness of any pressure ulcer prevention plan. If there are persistent signs of redness over a pressure area, the prevention plan needs intensifying. The resilience of skin in older adults is often impaired. Any prevention plan should consider the use of emollients if the skin is dry or barrier products if the skin is excessively moist (Bou et al, 2005; Beekman et al, 2009).
Keep moving (repositioning)
It is an important aspect of care for all older adults to maintain mobility and activity as much as possible, particularly whilst in hospital. The campaign to prevent Deconditioning Syndrome of older adults in hospital- “Sit up, Get Dressed, keep moving”: launched in 2017 (BGS) is addressing the culture change which is required to prevent the adverse effects of older adults being immobile whilst in hospital. In addition to the development of pressure ulcers, adverse effects include loss of self-confidence, increased risk of falls, and demotivation.
Incontinence and moisture
Individuals have an increased risk of developing moisture lesions and pressure ulcers if their skin is too damp, due to incontinence, sweat or a weeping wound. Continence assessment and appropriate interventions are important. Skin surface is normally slightly acidic and the content of urine and faeces are alkaline, when left in contact with the skin for any length of time they cause damage, which is similar in nature to a chemical burn. These can be very painful despite appearing to be superficial. Barrier creams are an effective treatment.
Nutrition and Hydration
Assessment of nutritional status should be part of the routine care of any patient, using the Malnutrition Universal Screening Tool (MUST), and forms a key aspect of any pressure ulcer prevention plan. A UK survey of 11,278 people in hospitals, care homes and mental health units found 28% of hospital patients and 30% of care home residents to be malnourished (Russell & Elia, 2007). It is well recognised that many older adults are vulnerable to poor nutrition (Guigoz et al, 2002; Cereceda et al, 2004). The Survey of UK Care Homes undertaken between 2007-2011 (Bapen 2015) found that malnutrition was found to be a major social health problem affecting 35% of care home residents.
The International Pressure Ulcer Guidelines recommend that any patient who is recognised to be poorly nourished and at risk of pressure ulceration should be referred to a dietician (NPUAP/EPUAP, 2009). They also recommend that patients who are both at nutritional risk and pressure ulcer risk should be offered a minimum of 30-35 kcal per kg body weight per day, with 1.25-1.5g/kg/day protein and 1ml of fluid intake per kcal per day. The use of nutritional supplements between meals may be a useful way of increasing intake.
All patients with a grade 3 or 4 pressure ulcer should be referred to a dietitian.
6. Pressure Ulcer Treatment
Many of the strategies used for pressure ulcer treatment are the same as those employed for pressure ulcer prevention, although they may be more intensive than those used in prevention. For example, a more sophisticated support surface may be required. It may be helpful to identify the factors/events which led to the development of the pressure ulcer so that they can be addressed where possible. It must also be accepted that for some patients, palliative care may be more appropriate than curative treatment.
This section focuses mainly on the wound care aspect of pressure ulcer treatment. Assessment of the pressure ulcer should include:
- Category – shows severity
- Position on the body – may affect dressing selection
- Level of exudate – will affect dressing selection and frequency of dressing change
- Pain assessment – many ulcers are painful for the patient
Having assessed the ulcer, the treatment objectives and plan of care can be determined. The overall all goals are to achieve a healthy wound bed and promote healing, however, wound debridement and control of exudate may be necessary in the first instance. An appropriate wound management product should be selected meet the wound requirements. Table 1 provides information about the range of products that are widely available. Keeping a record of simple measurements and wound appearance will provide information about the progress of the ulcer. Pain management will ensure the patient is comfortable.
Table 1: Wound Management Products in General Use
Alginates: Useful for all wounds with moderate to heavy exudate
Cadexomer iodine: Use for sloughy or infected wounds with heavy exudate
Capillary - action: Wicks exudate away from wound surface, only for heavily exuding sloughy wounds
Films: Use with care on fragile skin. Best on epithelialising wounds with low exudate
Foams: Foams have variable levels of absorbency depending on the brand. Best on granulating wounds
Honey; May be found as a topical or in combination with other products e.g. alginate. For use in infected wounds
Hydrocolloids: May be used for most types of wounds with low to moderate exudate. Not suitable for infected wounds
Hydrocolloid - fibrous: Greater absorbent capacity than hydrocolloids. Useful for wounds with moderate to heavy exudate
Hydrogel: Donate moisture to dry sloughy or necrotic wounds and assist autolytic debridement. Can be used on wounds with low exudate. Not suitable for infected wounds
Silver: Silver is an antibacterial and is generally found as a composite dressing with other products e.g. alginates, foams, hydrocolloids. Use on infected wounds
Soft polymers: These dressings are non-adherent and best used on granulating wounds. Some incorporate a pad for greater absorbency
Healing may not be a fast process, but generally as long as the patient has adequate pressure redistribution, good nutrition and appropriate wound management, the ulcer will heal in most instances.
7. Safeguarding and Pressure Ulcers
Pressure ulcers grade 3 and 4 are to be reported as a serious incident as set out within the Serious Incident framework (2015/16) and reported via the Strategic Executive Information System (STEIS) and potentially assessed for evidence of neglect or abuse. Geriatricians and other Health professionals who are concerned that a pressure ulcer (or other forms of skin damage) may have arisen as a result of poor practice, neglect, acts of omission or deliberate harm have to decide whether to make a safeguarding alert in in line with their local multi-agency safeguarding policy and procedures. The Care Act (2014) is the legal framework that requires health and social care professionals to promote transparency within multi agency partnership approach to safeguard and protect from harm people who are or who become vulnerable. Geriatricians should be aware of their local policies in this regard and understand their role in working collaboratively in any investigation.
8. Models of Service Provision
In the UK, pressure ulcer prevention and management is usually supported by local tissue viability services run by Tissue Viability Nurses (TVNs). The core of this role is the provision of specialist advice to clinical teams to plan care provision for individual patients where a complication has prevented the normal healing process. Policy development, audit, education and the provision of pressure relieving equipment such as mattresses and cushions are also integral parts of their role.
9. Responsibilities / Role of the Geriatrician / Nurse and AHP
Individuals between 70 and 75 years of age have double the incidence of pressure ulcers compared with 55 to 69-year-olds. The greatest incidence of pressure ulcers occurs in the 80 to 84-year age group (Perneger et al, 1998). More than two-thirds of older adults with pressure ulcers are female. Health professionals working with older adults will, therefore, encounter individuals at risk of pressure ulceration as well as those with established pressure ulceration on a regular basis. As part of Comprehensive Geriatric Assessment and MDT working they are best placed to manage such individuals appropriately. Additionally, familiarity with risk stratification scales and relevant, often local, guidelines and policies will prove invaluable adjuncts to optimal manage
10. Audit (including clinical governance)
Audit of pressure ulcers takes the form of prevalence and incidence surveys. They are generally undertaken by the TVNs and may form part of the CQUIN in some regions. Pressure ulcers may also be the subject of root cause analysis and serious untoward incidents reports. The NICE Quality Standard 89 (2015) contains quality measures to be undertaken by services. The prevalence of pressure ulcers is 1 of the 4 common harms recorded in the NHS Safety Thermometer, a local improvement tool for measuring, monitoring and analysing patient harms across a range of settings provides monitoring of the incidence of ulcers. The use of care bundles, such as SSKIN bundle, facilitate the process of audit in clinical settings
- A Comprehensive Geriatric Assessment will identify relevant patient factors in relation to pressure ulceration which ensure an effective management plan
- The majority of pressure ulcers can be prevented using appropriate prevention strategies
- Patients should have a comprehensive skin and nutritional assessment as well as assessment of their risk profile before determining a prevention plan
- All Practitioners should be familiar with national guidance and protocols regarding pressure ulcers that may have arisen from poor practice, neglect acts of omission or deliberate harm, and their role in raising potential safeguarding alerts.
- Patients with established pressure ulcers require intensified prevention strategies and an overall wound assessment including pain assessment.
- Auditing pressure ulcer incidence is an important method of monitoring the quality of patient care.
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